VS507090

Consulate General of Kenya in Los Angeles

Park Mile Plaza, Mezzanine Floor
4801 Wilshire Boulevard
Los Angeles, CA 90010
Tel: (323) 939-2408
Fax: (323) 939-2412
Email- info@kenyaconsulatela.com
http://kenyaconsulatela.com
VISA APPLICATION FORM
(To Be Completed In Block Letters)
VISA TYPE : Single $50.00
Young Sang
Cha
1. A. Surname (Mr. /Mrs. / Miss) _______________________
B. Other Names In Full ______________________

C. Full Name Father/ Husband/ Wife_____________________________________________________

Seoul, KR
Male
27/02/1984
2. A. Date of Birth ___________________Country
and Place of Birth ___________________Sex
____________
Product Manager
B. Profession/ Occupation __________________________________________________________________
US
3. A. Country of Residence ___________________________________________________________________

US
US
B. Nationality at Birth _________________________
C. Present Nationality, if different __________________

4. Passport/ Travel Document Held:

44419013
United States, 06/06/2008
A. No: _______________________________Place
& Date of Issue_________________________________
United States Department of State
B. Issued By _____________________________________

05/06/2018
Valid Until ______________________________

(Name of Authority issuing Passport/ Travel Document)

5. Contact Address and Telephone number in the USA___________________________________________
3710 w 244th st Torrance, California, 90505 3104137305
______________________________________________________________________________________
vacation
6. A. Reason For Entry______________________________________________________________________

23/09/2012
01/10/2012
B. Proposed Date of Entry ______________________________________
Duration of Stay_______________

7. Full names and Addresses of Friends, Firms or Relatives To Be Visited, if any:

______________________________________________________________________________________
3103782138 3104137305
______________________________________________________________________________________

8. Dates and duration of previous visits to Kenya __________________________________________________

Yes
9. Will You Be Returning To Your Country of Residence/ Domicile?_____________________________________

10. It should be noted that possession of a visa is not the final authority to enter Kenya.
I hereby declare that the foregoing particulars are correct in every detail.
07/09/2012 13:23:20
Date: __________________________
Signature of Applicant: ______________________________________